ROANOKE TIMES
Copyright (c) 1996, Roanoke Times
DATE: Sunday, February 11, 1996 TAG: 9602090095
SECTION: HORIZON PAGE: F-1 EDITION: METRO
DATELINE: PHILADELPHIA
SOURCE: PETER T. KILBORN NEW YORK TIMES NEWS SERVICE
At a time when the federal government is driving down the cost of health care and forcing hospitals across the country to close, the Department of Veterans Affairs keeps expanding its own hospital system, the nation's largest, and spending more for health care.
Government reports call the Veterans Health Administration a bloated bureaucracy, with surgeons who have gone a year without lifting a knife, and rife with wasteful practices like admitting clients to hospitals for conditions that outpatient clinics everywhere else treat in an hour or two.
A quarter of the beds in the VA's 173 hospitals stand empty as the surviving soldiers of World War II move into their 70s and 80s and the veteran population shrinks. There are 26 million veterans now, down from 30.1 million in 1980.
Yet in Washington's battle over the 1996 budget, President Clinton has proposed an increase of more than $700 million for the Veterans Health Administration, mostly for new construction, and the Republican-dominated Congress has approved an increase of $400 million. At the same time, Medicare, the government insurance program for the elderly, and Medicaid, the program for the poor, face sizable cuts in projected spending.
VA jobs have grown with the spending. The federal work force shrank 8 percent, to 2 million, since the Clinton administration took office through September, according to the Office of Personnel Management. But the VA work force climbed 1.4 percent, to 264,000.
The veterans hospital system bucks the trends in health care because no one can touch it politically. Clinton, denounced by many veterans for avoiding the Vietnam War draft, has bent backward to court them.
Members of Congress, sensitive to jobs the hospitals provide in all 50 states, recoil at shutting one in their own. And lobbies like the American Legion, the Disabled American Veterans and the Veterans of Foreign Wars boost the interests of veterans unchallenged by other groups.
VA officials themselves say they have too many hospital beds.
``Every place is overbedded,'' said Kenneth Kizer, the department's Under Secretary for health, who is attempting to reorganize the system. Kizer said he was also cutting his headquarters staff to 600 from 802.
But he blames Congress for some of the redundant capacity and for writing some of the regulations that discourage the department from turning to less expensive outpatient care, a development that is rapidly changing the American hospital system. ``People are admitted to hospitals who don't have to be admitted,'' he said. ``But the only way they can be treated is to be admitted.''
Officials in Congress acknowledge the political difficulties of cutting the budget of an agency that serves the nation's veterans, even at a time when they are struggling with some of the deepest budget cuts in history.
``You mention the word `veteran,' and you're supposed to pitch forward on your sword,'' said Sen. Alan Simpson, R-Wyo., and chairman of the Veterans' Affairs Committee. He said no one begrudges a battle-scarred infantryman a lifetime of medical care, a disability check and a pension for him and his widow.
But the veterans' lobbies ``raise tremendous amounts of money,'' Simpson added. ``They tell their public this Congress doesn't care about their vets. I'm a veteran. If I weren't, they'd have cremated me by now.''
Veterans' groups forced Edward Derwinski to resign as President Bush's secretary for veterans affairs in 1992 after he suggested admitting nonveterans to a few underused VA hospitals.
``With welfare, abortion, gun control, the death penalty,'' Derwinski said, ``you've got legitimate pro and con positions. But there's no anti-vet lobby. No one's going to come in and say, `Don't waste any more money on veterans.'''
With its network of hospitals and more than 500 clinics, nursing homes and other facilities, including about 20 golf courses, the Department of Veterans Affairs runs the nation's largest health system.
That system, which cares for about 2.6 million veterans, is in line to receive $16.6 billion in the fiscal year 1996. By contrast, said a Senate aide who specializes in veterans affairs, the Department of Defense spends about half as much for the care of 8 million soldiers and dependents.
In defense of the system, veterans advocates say the budget, while growing, has fallen behind the pace of rising health care costs and that veterans, while declining in number, are reaching ages when they need two and three times more care than they did in their 30s and 40s.
The advocates say fewer hospital beds would be empty if the government relaxed eligibility rules for free care. All veterans can use the hospitals, but just 10 percent do, mostly those whose expenses are paid. To qualify for free care a veteran - anyone who has served at least 180 consecutive days in the armed forces - must earn less than $20,469 or be deemed at least 50 percent disabled by injuries or diseases contracted in the service.
The system's supporters also say that the hospitals have developed invaluable expertise in researching and treating service-related conditions, like spinal cord injuries, amputations, hypertension and acute mental disorders, and that they maintain a culture that is especially responsive to the concerns of veterans.
``It's a place where other things happen than health care,'' says Dr. John Lipkin, chief of staff of an immense old veterans medical center in Perry Point, Md.. ``Vets are protective of a system that treats them in a different way. They feel there is no net out there that meets their needs.''
Waiting for a prescription to be filled in the Philadelphia veterans hospital the other day was John Edison, 62. He told of getting his left hip damaged by shrapnel in Korea when he was serving in the infantry. Much later he developed lung cancer. He had a lung removed and received chemotherapy and radiation, all here, all free.
Robert Woerner, 63, was a boiler tender on a destroyer in the Korean War who emerged without injury or an illness. But recently, he mangled his left arm.
``I was drunk,'' he said, ``and I fell off a building. Four stories.'' He said the hospital had sent him to a veterans alcohol treatment center.
Also waiting for medication was Bill Berghandler, 42, who was a mechanic in the Marines in the Vietnam War.
After tests at a private hospital three years ago, Berghandler learned he had HIV, the virus that causes AIDS. ``The doctor wouldn't come near me,'' he said. ``He ignored my complaints.''
On Medicaid then, Berghandler switched to the veterans hospital here. ``I had to have my spleen taken out,'' he said. ``The day after I was discharged for that, they found blood clots in my stomach and I had to have six feet of intestine removed. There's a new drug now they're letting me use.''
He said he had decided not to go back to Wisconsin, where he grew up, because of the care he gets at the veterans hospital here.
In spite of the declining number of veterans, the department shut only two hospitals since the 1960s, both in California and both because of earthquakes. It has mothballed or eliminated half the hospitals' beds since then, but it is filling fewer than 75 percent of those that remain.
Veterans hospitals would be even emptier if they were keeping up with the shift toward less expensive outpatient care that has been shutting community hospitals at a rate of three a month for nearly two decades. That process is sure to accelerate. Both the president and Congress are committed to cutting tens of billions of dollars from projected spending for Medicaid and Medicare.
The Clinton administration and Congress are encouraging less hospital use. Special Medicare payments that help support teaching hospitals could be curbed. All parties in the debate agree that the country is glutted with hospitals and that in the bloodletting likely to follow enactment of the 1996 budget, many more will close.
Yet in the dispute over the budget, few agencies have proven more immune to these pressures than the Veterans Health Administration. Clinton and his Secretary for Veterans Affairs, Jesse Brown, proposed in this year's budget not to close hospitals but to spend $343 million for two more, in California and Florida.
The Republican Congress's budget committees vetoed the new hospitals. But they approved spending $50 million to build clinics at each site, and to pay for work at other hospitals.
As a result, the Veterans Health Administration is expected to receive at least, $400 million, or 2 percent, more in the fiscal 1996 budget than it was granted in 1995. Since 1990, spending on health care for veterans has risen 43 percent, four times the pace of all other spending whose levels are set by Congress or the Clinton administration.
The department's year-upon-year success in winning bigger budgets illustrates paradoxes of political expediency.
Republicans in Congress who stopped the president's overhaul of the nation's health care system in 1994 on grounds that it smacked of big government nevertheless condone a big-government health care system for former soldiers. And in the budget debate, lawmakers who would restrict guaranteed care for the poor through cuts in Medicaid go along with unrestricted care for all poor and many better-off veterans.
Meanwhile, Clinton has assiduously sought the favor of veterans. In picking Brown, he chose a former president of the Disabled American Veterans who calls himself a career lobbyist for veterans.
Brown, who declined to be interviewed, has said he shares the view of veterans' organizations that anyone who serves in the military is special and deserves privileged care.
Yet in audits, both the General Accounting Office and the department's own inspector general have raised fundamental questions about the department's health care mission and management.
In a look at six hospitals, in 1990, the inspector general found that 21 of 131 surgeons ``spent no time in the operating room at all during the year.'' Four years later, in an audit of three other hospitals, it found that 13 of 79 surgeons went a year without lifting a knife.
By dwelling on building and renewing hospitals, the reports showed, the VA resists the trend toward outpatient care and keeps patients in hospitals much longer than community hospitals do.
The department's annual report for 1994 shows a 17 percent increase in outpatient visits from 1987 to 1994. But over the same period outpatient visits in the private sector jumped about 50 percent.
Part of the problem is regulations like those that require hospital stays for many procedures, including cataract operations, that are routinely performed by outpatient clinics in the private sector. Kizer said such regulations even apply to giving a patient a pair of crutches.
``A patient comes in with a broken ankle,'' he said. ``It is casted in the emergency department. He needs crutches. Well, crutches are called a prosthetic device. Prosthetic devices are only given on an inpatient basis. So he has to be admitted to the hospital. Every place else in the world just gives him a set of crutches and lets him go home.''
Earl Falast, director and chief executive of the Philadelphia center, said he has cut some fat, reducing the number of hospital beds to 330 from 450 and raising the number of outpatient visits to 321,000 from 250,000. He has also reduced staff to 1,820 from 1,980.
But regulations intrude upon such initiatives. Because Congress has mandated that hospital employment systemwide be kept constant, Falast cannot cut staff members until officials in Washington have agreed to add positions elsewhere.
Critics say both veterans and taxpayers could be served at less cost by wholly different means. ``The real question is whether there should be a veterans health care system at all,'' said Richard Cogan, a senior fellow at the Center on Budget and Policy Priorities in Washington.
Rep. Bob Stump of Arizona, a Republican and chairman of the House Veterans' Affairs Committee, said closing hospitals was politically difficult.
``You're talking about something that would be worse than base closings,'' he said. But he added, ``We're going to try a program of letting some guys go into any hospital and see what happens.'' he said.
Kizer appears to be pushing the department in that direction. An outsider appointed a little over a year ago after a career in health-system management, he is reorganizing the hospitals, linking them into regional groups, eliminating duplication and trying to force a faster shift to outpatient care.
But he said little can happen without Congress's help. ``Our biggest impediment to change is the failure of Congress to give us the tools,'' Kizer said.
``Congress acknowledges that the laws aren't consistent with where health care is today,'' he said. ``But they won't do anything.''
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